A product of millions of years of evolution as social beings, generally we desire that those with whom we share a genetic interest do not die.

Evolution has favoured the hard wiring of strong physiological emotional reactions reinforcing behaviours that protect one another from harm. Whether as an orang-utan grieving for the death of its infant, or a human struggling to accept the death of a parent, we are driven to avoid the sensations of loss that are inextricably linked to the benefits of bonding.

Critically, all social animals also have a vital interest in the overall survival of their group on which they and their offspring are dependent. The power of bonding can never trump the competing necessity that communities make resource allocation decisions for the long term.

As an example, for thousands of years migratory hunter–gatherer communities living in the Paraguayan forest, having exhausted local resources, had to move a number of kilometres at regular intervals. Any adult who became unable to walk was left behind, as were small children who did not have anyone to carry them. These decisions were not made without significant emotional distress; one man told anthropologists that he had buried his mother alive because he did not want her to be eaten by a jaguar when she was left behind in the forest.

Fast forward to the 21st century.

We now live in a very different paradigm. The success of our technology generally allows us to ignore the day-to-day reality of inevitable death.

The abstract concept of money allows us to be generally detached from the gathering of resources, and we can ignore the complexity of how their distribution is decided. At the same time, we have become disconnected from the diffuse consequences of the resource allocation decisions that are made.

In isolated communities such decisions were overt; the son knew that his community, having eaten all that was available in the area around their encampment, had to move on. He understood that the long-term interests of his community (and therefore of his genes) left him with no choice and he took responsibility for his actions. He accepted the emotional consequences of grief and guilt and knew that if he survived to old age the same thing would happen to him.

The dynamic relationship between the value that we place on individual lives and the need to act in the long-term interests of the community has become invisible. Our focus on the needs of the person in front of us has led us to expect that priority will be given to prolonging every individual life and to forget the imperative to protect the overall viability of our community.

As patients in complex modern societies we are grateful for the benefits of the treatments we receive. As doctors we often profit handsomely from the decisions we encourage our community to make for our patients. We are all detached from personal responsibility for the patients of others from whom resources are withheld and are generally unaware of what happens to those who miss out.

Unlike the decision making of those living in the Paraguayan forest, our resource allocation process is covert. Consequences seldom play out when and where choices are made. They may be lived far away, suffered as a different disease, or lurk as a potential illness that we have not yet failed to prevent.

We have become disconnected from the broad-scale impact of decisions that divert resources from priorities outside of health: education, the environment or infrastructure. Those consequences may not be manifest for decades or even generations, by which time the causal decisions are long forgotten.

While politicians may focus on the short term, leaders can help us to understand the long-term interests of our society. As citizens we all have a responsibility to maintain the balance between the humanity that has us caring for the sick and our responsibility to act for the future success of our community.

We are not so special, or so rich, that we can escape the need for wise and difficult decision making in the allocation of our resources.

2 thoughts on “Resource allocation: making wise choices”

An excellent article that should be more widely read. We in medicine have become disastrously removed form the economic consequences of our decisions. The public squeal whenever any politician tries to introduce or increase any price signal that may make them think twice about demanding care. We are all sleepwalking towards a cliff edge together

The author implies the view – which is supported by sound evidence – that wise expenditure on matters not directly related to health, eg. public infrastructure such as well-designed public transport, or good provision of education, can have enormous benefits for the physical and mental health of most community members; and that much expenditure on the current health system provides little benefit and can be considered wasteful. I recommend to readers the critique of aspects of contemporary medical culture provided by the various writings of the iconoclastic Stanford epidemiologist, Professor John Ioannidis.